老年重度慢性阻塞性肺疾病的预后研究

目的探讨重度慢性阻塞性肺疾病(COPD)患者的生存期影响因素,指导临床评估病情并制定相应的干预措施。方法采用前瞻性研究方法,于1993年5月起对符合重度COPD稳定期的老年患者178例逐一入选,2010年12月为观察终点时间。分别对入选患者进行基线调查,对生存状况、是否应用无创呼吸机、死亡原因进行随访。对入选者进行生存分析,并进一步按肺功能分层进行生存分析。有意义影响因素进一步进行生存率的比较。结果 COPD队列中5年生存率为49%,10年生存率为12%,年龄(RR=1.043,95%CI为1.010～1.050)、第1秒用力呼气容积(FEV1,RR=0.019,95%CI为0.007～0.052)、FEV1占预计值百分比(FEV1%pred,RR=1.045,95%CI为1.012～1.079)、肺功能分级(RR=2.542,95%CI为1.310～4.931)、体重指数(BMI,RR=0.945,95%CI为0.895～0.952)、肺心病(RR=1.872,95%CI为1.188～2.959)均为影响生存期的因素。在重度肺功能分级患者中,影响生存时间的独立预测因素有呼吸机(RR=1.167,95%CI为0.041～1.674)、肺心病(RR=3.805,95%CI为1.336～10.836)、FEV1(RR=0.081,95%CI为1.001～1.168)及PaO2(RR=0.956,95%CI为0.920～0.993)。在重度COPD患者中,应用呼吸机患者生存期较未应用呼吸机患者长,应用呼吸机患者的5年和10年生存率分别为78%和50%,均高于未应用呼吸机患者的30%和25%。在极重度肺功能患者中,影响生存时间的独立预测因素有FEV1(RR=1.059,95%CI为1.015～1.105)、PaCO2(RR=1.037,95%CI为1.001～1.074)、年龄(RR=1.054,95%CI为1.013～1.096)及肺心病(RR=1.892,95%CI为1.125～3.181)。结论年龄、BMI、FEV1、PaO2、PaCO2、肺心病、呼吸机的应用是预测老年重度COPD患者预后的重要因素。重度和极重度COPD患者预后影响因素不完全相同。对于重度COPD患者应给予早期干预,积极营养支持,长期家庭氧疗联合无创机械通气,改善氧合状况,缓解呼吸肌疲劳,改善患者生活质量,提高长期生存率。

Prognostic Factors of Severe Chronic Obstructive Pulmonary Disease in Elderly Patients:A Long-term Follow-up Study

Objective To investigate the prognostic factors of sever e chr onic obstructive pulmonary disease(COPD) in elderly patients,and to guide th e clinical assessment and appropriate interventions.Methods A prospective cohor t study was carried out from May 1993 to December 2010.A total of 178 elderly pa tients with severe COPD were recruited for baseline survey,and followed up for the living conditions,whether used non-invasive ventilation,and causes of dea t h.A survival analysis was performed on all patients stratified by lung function. The significant factors on survival rate were analyzed.Results In this cohort t he survival rates were 49% and 12% in five and ten years,respectively.The impor tant factors for prognosis were age [relative risk(RR)=1.043,95% confidence intervals(95%CI=1.010-1.050],forced expired volume in one second(FEV 1,RR=0.019,95%CI=0.007-0.052),FEV1%pred(RR=1.045,95%CI=1.012-1.079),lung funct ion grade(RR=2.542,95%CI=1.310-4.931),body mass index(BMI,RR=0. 945,95%CI=0.895-0.952),and pulmonary heart disease(RR=1.872,95%C I=1.188-2.959).In severe COPD,non-invasive ventilation(NIV,RR=1.167,95%CI=0.041-1.67 4),pulm onary heart disease(RR=3.805,95%CI=1.336-10.836),FEV1(RR=0.081,95%CI=1.001-1.168),and arterial partial of oxygen(PaO2,RR=0.956,95%CI=0.920-0.993) were the independent predictors. The patients using NIV had longer survival than those without NIV.The 5 and 10 years survival rate in the patients with NIV wer e 78% and 50%,much higher than those without ventilation which were 30% and 25%,respectively.In extremely severe COPD,FEV1(RR=1.059,95%CI=1.015-1.105),a rterial partial of carbon dioxide(PaCO2,RR=1.037,95%CI=1.001-1.074),age( RR=1.054,95%CI=1.013-1.096) and pulmonary heart disease(RR=1.892,9 5%CI=1.125-3.181) were the independent predictors.Conclusions Age,B MI,FEV1,PaO2,Pa CO2,pulmonary heart disease,and NIV were prognostic factors in elderly patie nt s with severe COPD.The prognostic factors between severe and extremely severe CO PD were not identical.Patients with severe COPD should be given early interventi on,including progressive nutritional support,and long-term home oxygen therapy combinin g with NIV.